A nurse is collecting data from a client who is recovering from a recent stroke.
Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?
Coughing while eating.
Fine motor tremors.
Facial flushing.
Urinary incontinence.
The Correct Answer is A
Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.
Choice B is wrong because fine motor tremors are not related to speech or language problems.
They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.
Choice C is wrong because facial flushing is not related to speech or language problems.
It may be caused by high blood pressure, fever, anxiety or other conditions.
Choice D is wrong because urinary incontinence is not related to speech or language problems.
It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.
The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.
Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.
Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.
Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.
Correct Answer is A
Explanation
Transferring the client from the bed to a chair. This is a task that can be delegated to an assistive personnel because it does not require nursing judgment or assessment. The nurse should provide clear instructions and supervise the assistive personnel during the transfer.
Choice B is wrong because checking the client’s surgical dressing for bleeding is a nursing assessment that requires clinical judgment and cannot be delegated.
The nurse should monitor the dressing for signs of infection, drainage, or dehiscence.
Choice C is wrong because determining whether the client has incisional pain is a nursing assessment that requires communication and evaluation skills and cannot be delegated.
The nurse should assess the client’s pain level, location, quality, and duration and administer pain medication as prescribed.
Choice D is wrong because showing the client how to use an incentive spirometer is a nursing intervention that requires teaching and evaluation skills and cannot be delegated.
The nurse should instruct the client on how to use the device to promote lung expansion and prevent atelectasis.
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